STUDENT INFORMATION *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Student Phone (optional)

(###)

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Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which BBIT Program would you like to Register for? *

DISCOVER (1st-3rd grade)

EXPLORE (4th-6th grade)

PIONEER / Tech Club (7th-9th grade)

INNOVATE (10th-12th grade)

PARENT & EMERGENCY CONTACT INFORMATION *

First Name

Last Name

Parent Phone *

(###)

###

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